Provider Demographics
NPI:1821836651
Name:WICKENS, EMILY ANN
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ANN
Last Name:WICKENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 S 2500 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-3241
Mailing Address - Country:US
Mailing Address - Phone:702-338-0117
Mailing Address - Fax:
Practice Address - Street 1:27 S MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-5888
Practice Address - Country:US
Practice Address - Phone:801-581-6437
Practice Address - Fax:801-581-7177
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program